Developing an agenda for the decolonization of global health

Abstract Colonialism, which involves the systemic domination of lands, markets, peoples, assets, cultures or political institutions to exploit, misappropriate and extract wealth and resources, affects health in many ways. In recent years, interest has grown in the decolonization of global health with a focus on correcting power imbalances between high-income and low-income countries and on challenging ideas and values of some wealthy countries that shape the practice of global health. We argue that decolonization of global health must also address the relationship between global health actors and contemporary forms of colonialism, in particular the current forms of corporate and financialized colonialism that operate through globalized systems of wealth extraction and profiteering. We present a three-part agenda for action that can be taken to decolonize global health. The first part relates to the power asymmetries that exist between global health actors from high-income and historically privileged countries and their counterparts in low-income and marginalized settings. The second part concerns the colonization of the structures and systems of global health governance itself. The third part addresses how colonialism occurs through the global health system. Addressing all forms of colonialism calls for a political and economic anticolonialism as well as social decolonization aimed at ensuring greater national, racial, cultural and knowledge diversity within the structures of global health.


Introduction
Medicine and public health have always been shaped by social and political values, 1 as evident in efforts to redress social inequities in health, struggles to realize health as a universal human right and, more recently, in calls to decolonize global health. 2Indeed, reviewing global health through the lens of colonialism or coloniality provides an opportunity to consider the role of power, injustice and exploitation in the practice of global health.However, much of the current interest in decolonizing global health has been focused on the domination of global health by actors and institutions from high-income and historically privileged countries, and the resulting hierarchies in knowledge production.Less attention has been paid to new forms of colonialism and how the complex of global health structures and systems may itself be a channel for extractive colonial practices.In this paper, we provide a more comprehensive discussion of colonialism and its manifestations in global health, and offer a conceptual framework to identify the different sites and forms of colonial practice and how these practices can be countered.

Understanding colonialism
We define colonialism as one group of people having the power to dominate, subjugate and/or exploit another group or groups of people, thereby enabling the misappropriation and extraction of resources in a large-scale and systematic manner.These resources may be human resources in the form of cheap, indentured or enslaved labour; natural resources such as fertile land, minerals, oil and genetic material from plants and microorganisms; and intangible resources such as data and knowledge.Colonialism is most commonly associated with imperialism and the conquest, control or occupation of foreign lands.Thus, decolonization is most often used to describe the physical withdrawal of a foreign power from its colonies and the establishment of new sovereign states.However, one must understand that colonialism manifests in different ways and that it is a contemporary phenomenon.
Ghana's first President, Kwame Nkrumah, coined the term neocolonialism to describe the continued extraction of resources and wealth from newly independent states by their former rulers and other foreign powers. 3This neocolonialism is achieved through indirect political and economic control -often backed with the use or threat of use of military force -including the use of financial and economic power to buy assets and capture markets, and the control of the institutions of global economic governance to establish advantageous monetary, trade and investment systems. 3Neocolonialism also involves powerful external actors working with postindependence governments and elites to continue systems of subjugation and exploitation, including systems established by their former colonial rulers.The large net outflow of resources and wealth from independent states in sub-Saharan Africa to beneficiaries in high-income countries is evidence of the scale and power of neocolonial forms of exploitation. 4,5olonial oppression and exploitation can also manifest internally within the borders of the modern nation state, including states that were former colonies.For example, having freed itself of British rule, the United States of America continued the colonization of indigenous native Americans and enslavement of millions of Africans.Today, in many countries, indigenous or minority communities are subjected to unjust political and economic systems and oppressive and exploitative arrangements that could be considered colonial.
A key feature of colonialism is its relationship with capitalism.Finance capital helps create and consolidate the economic, military and technological power of colonial actors.Furthermore, through its need to constantly seek out new sources of profit, capitalism drives the impulse to colonize.Capitalist colonial structures often involve governmental and private actors working together.British colonial rule in India and North America, for example, developed through evolving interactions between private corporations such as the East India and Hudson Bay companies and the British state. 6Today, much contemporary colonialism is organized around powerful private financial institutions and transnational corporations with control over large parts of the global economy. 7Underpinning this control has been a growth in the volume and mobility of financial capital, and the global integration of markets and supply chains under a largely neoliberal policy model, mostly implemented through global economic institutions such as the International Monetary Fund and World Trade Organization and many other multilateral, plurilateral and bilateral trade and investment agreements. 8entral to the various forms of globalized financial and corporate colonialism present today are: financial deregulation; the strengthening of intellectual property rights which may be equated to a colonization of knowledge; and the enablement of tax avoidance through the deregulation of transnational corporate activity and the tolerance of secretive banking regimes which allow public funds to be misappropriated. 9,10Financialization and the privatization of societal institutions that were previously considered public (e.g.education, health care, public utilities such as water and sewerage, and even prisons and policing) have further expanded opportunities for wealth extraction and accumulation. 11The effects of contemporary colonialism are considerable.As an ever-increasing share of profits across all economic sectors are enjoyed by a small transnational elite, workers across the world are experiencing falling wages, working conditions are deteriorating and becoming increasingly precarious, and hundreds of millions of people remain in extreme poverty. 12By one estimate, 10 men own more wealth than the poorest 3.1 billion people in the world. 12he pattern of wealth extraction today still mirrors the previous exploitative relationships between colonizing countries and their former colonies.However, today's globalized political economy has also altered the geography of colonialism.Contemporary colonialism is marked by the growth of extreme wealth and poverty in both rich and poor countries alike, and the emergence of a globalized class structure that includes an elite that transcends national, racial and religious identities, and rising numbers of impoverished people in high-income countries.The growing digitalization of the global economy also underscores the changing geographic contours of colonialism.Although the physical colonization of land 13,14 and other natural resources is still important, the virtual digital spaces through which so much economic activity now occurs is a new and important site of colonialism. 15Great wealth is now extracted through the rent-seeking practices of monopolistic technology (tech) companies with control over ecommerce platforms and large data sets of individual preferences and behaviours.In what has been labelled as surveillance capitalism, many people are now exposed to manipulative and targeted extractive marketing, as well as to unprecedented levels of intrusive surveillance and monitoring. 16undamental to all forms of colonialism is the use of ideas and narratives by colonialists to enable and legitimize colonial practices.Racist ideas of European moral and cultural superiority in public life, and the portrayal of colonial subjects as inferior, were powerful forces of European colonialism and central to its most brutal manifestations, including the extermination of indigenous populations and the trans-Atlantic slave trade.Racism and other forms of discrimination continue to shape exploitative and oppressive relationships today, as well as paternalistic approaches to development and humanitarian work. 17However, contemporary anticolonial struggles must also challenge economic ideas and narratives that are used to sustain and legitimize the extractive and exploitative practices of today's globalized colonialism.
These ideas and narratives include: false or exaggerated claims, delivered through powerful corporate media and networks of well-funded lobbyists, think tanks and research groups, about the virtues and benefits of unregulated markets and expanded intellectual property rights; manufactured misinformation about global warming; and the excessive devotion to technological innovation as a means to tackling the problems of poverty without any need for redistribution of resources or sociopolitical change. 18,19Furthermore, just as European colonizers used missionary doctors and teachers to portray themselves as saviours, corporate social responsibility and billion-dollar private foundations are used to portray today's economic elites as benevolent wealth creators or entrepreneurial problem-solvers for the world. 20Such narratives not only hide the true nature of contemporary colonialism, but also often reinforce power asymmetries by promoting proprietary knowledge and technologies as solutions to social and political problems.
The complex intersection between colonialism and gendered patterns of subjugation and exploitation also needs specific mention.All colonial powers typically impose their sociocultural norms and beliefs on colonized peoples.European colonialism, for example, imposed a particular form of patriarchy (including binary norms related to sex, gender and sexuality) through laws and practices that subverted local customs in some places, and which were used to control the bodies of marginalized groups in society. 21In more recent times, by contrast, certain forms of feminism that have arisen in some high-income countries have been used in low-income countries to address patriarchy and gender inequality, but sometimes in ways that may be seen as a form of cultural imperialism. 21At the same time, under today's globalized capitalist systems, gendered patterns of economic exploitation and their intersection with class and race are seen in the concentration of precarious, low-paid and sometimes dangerous work within the formal and informal economic sectors among women of colour and women in lowincome countries. 21Additionally, an unfair and disproportionate amount of unpaid care work is being done by women everywhere. 22 comprehensive conceptualization of colonialism must include an ecological dimension in the age of the Anthropocene (a new unit of geological time used to describe the most recent period in the Earth's history during which human activity has substantially affected the planet's natural and biophysical systems).Historically, colonialism and the underlying forces of capitalism have been associated with the plunder of natural resources and destruction of the natural environment, the effects of which were often disastrous to indigenous and local communities.23  Furthermore, the unequal contribution to greenhouse gas emissions and disproportionate negative impact of global warming on low-income countries and populations represent an ongoing injustice rooted in colonial history.24,25 Indeed, the prospect of future generations living on a planet stripped of the key ecosystem support required for human civilization may also be viewed as a form of intergenerational colonialism involving unjust and extractive relationships between populations in different periods of time.26 Pertinently, many of the indigenous cultures and knowledge systems that have been destroyed by colonialism instilled the idea that all generations have a custodial duty to protect the natural environment for future generations.26

Colonialism, medicine and health
Colonialism has shaped medicine and public health in various ways.For example, tropical medicine and tropical medicine institutes (e.g. the Institute of Tropical Medicine in Antwerp, and the London School of Hygiene and Tropical Medicine) were established to protect colonial personnel, maintain the productivity of native workers and aid imperial expansion.][29][30][31] Crucially however, medicine and public health also have anticolonial traditions.Among these traditions are the social medicine movement in Latin America in the 1950s, 32 as well as various health improvement initiatives in post-independence states that were built on the principles of social justice, equity, community mobilization, culturally appropriate technology and multisectoral action for health. 33,34hese initiatives laid the foundation for the World Health Organization's (WHO) 1978 Alma Ata Declaration, 35 which arguably remains the exemplary expression of anticolonial global health.Among other things, the Alma Ata Declaration called for a "new international economic order", "a genuine policy of independence" for developing countries and "peace, détente and disarmament" between nations.Two other anticolonial expressions of global health are: the People's Charter for Health 36 developed by the People's Health Movement, which expresses explicit resistance to neocolonialism within and beyond the health sector; and WHO's Commission on Social Determinants of Health, which highlighted power asymmetries and unjust and exploitative economic systems as core drivers of health inequalities. 37urrent discussions on decolonizing global health rarely address the aspirations of the Alma Ata Declaration, the community organizing and empowerment processes exemplified by the People's Health Movement, or the political economy reforms laid out by the WHO Commission on Social Determinants of Health, all of which are about tackling inequity and injustice in health.To draw from these anticolonial expressions would require an expanded decolonizing global health agenda that would need to address the domination of global health by actors, institutions and knowledge systems in some highincome countries, as well as the undue influence on global health of powerful financial and corporate interests, and their unethical and excessive extraction of wealth through the health sector. 38,39elow we present a three-part agenda for action that can be taken to decolonize global health.

Colonialism within global heath
The first part relates to the power asymmetries and unequal relationships that exist between better-resourced and privileged institutions in high-income countries and their counterparts in lower-income countries. 40These asymmetries include the structural inequalities in global health education which results in the dominance of universities in high-income countries in global health teaching and research; the financial subsidy of those universities by students from low-and middle-income countries who undertake their education in these colleges; and a contribution to the so-called brain drain from poorer to wealthier countries.Similarly, structural inequalities in global health research produce so-called parachute research (a term used to describe the practice of external researchers dropping into lowincome countries and communities for short periods of time to collect research data, and then leaving); and unfair research partnerships, maldistribution of benefits in the form of publications, authorship and citations, kudos or patentable knowledge, and neglect of indigenous knowledge systems and cultures. 41nequitable relationships within global health also manifest in the dependency of poorer countries on external donors and agencies who provide development assistance in ways that fragment and undermine coherent and locally appropriate health systems development, 42 or that impose the cultural norms of some high-income countries. 43n anticolonial agenda within global health must therefore be pursued at two levels.First, actors who are part of relationships and partnerships within global health must be more aware of and sensitive to structural power asymmetries, and must adopt guidelines and codes of conduct aimed at eliminating disparities, preventing unethical practices and instituting mechanisms of mutual accountability. 44Second, because aid agencies of high-income countries and private foundations can shape the pattern and nature of relationships within global health, more attention needs to be paid to evaluating the funding and grant-making patterns of these institutions and holding them accountable for perpetuating or worsening the unequal relationships prevalent in the global health system.

Colonization of global health
The second part relates to the dominance over the structures and systems of global health governance by certain actors and by particular ideas and narratives.This dominance can be traced back to the way powerful actors challenged and undermined the anticolonial vision of the Alma Ata Declaration and then proposed the more conservative vision of selective primary health care. 45This dominance can also be seen in the opposition to WHO's efforts to promote essential medicines lists and the use of generic medicines, and to stop the marketing of breast milk substitutes. 468 Although multistakeholder models of governance promise greater participation of different stakeholders, these models can also undermine the authority of intergovernmental organizations, while expanding opportunities for powerful private actors to exert influence over governing structures, and concentrating power among parties with less democratic accountability to poorer countries and populations. 49mong other things, this situation results in: promotion of selective saleable biotechnological ideas and interventions (often packaged as innovations); 50 powerful and private actors being shown in a charitable light; global health security discourses that emphasize the protection of wealthy countries and populations from infectious disease threats from poor countries; 51,52 and priority-setting exercises that ignore the structural drivers of disease and ill health in poor countries and populations. 53n agenda to decolonize global health itself would need to include restoring the authority and capacity to intergovernmental organizations, especially WHO, to coordinate and manage global health as an international concern.At the same time, such an agenda must find ways to make global-level governance more democratic by, for example: enabling the participation of grassroots voices and social movements in global health; improving representation of perspectives from lower-income countries on technical working groups and in global health conferences; and creating new mechanisms to make powerful global health actors more accountable. 54Improved diversity and inclusion of different stakeholders in the institutions of global health governance are important.At the same time, however, efforts to overcome underlying power and resource asymmetries will require global health actors to promote fundamental reforms of the political economy aimed at redistributing wealth, 55 such as those advocated by the WHO Council on the Economics of Health for All, 56 and the United Nations High-Level Advisory Board on Effective Multilateralism. 57

Colonialism through global health
The third part concerns the way exploitation and wealth extraction occurs through the health sector.Although health care is generally benevolent, it is also a trillion-dollar economic sector that creates incentives and opportunities for economic exploitation.The coronavirus disease 2019 (COVID-19) pandemic illustrated this potential for exploitation.The power of pharmaceutical companies and their financial backers, supported by a corporate-friendly system on intellectual property rights, resulted in billions of dollars of profit being generated from a global health emergency that left hundreds of millions of households economically overwhelmed. 38The past few decades have seen more parts of the health sector becoming financialized and controlled by a small number of companies, which has created opportunities to extract wealth from public budgets, patients and frontline workers (through downward pressure on wages and increased precariousness in employment conditions). 39The control by a few big tech companies of digital health, for example, provides many opportunities to make large profits. 58Some of these profits are channelled through tax havens, denying public institutions and services vital revenue. 59n agenda to prevent wealth extraction through global health would similarly need to engage with reforms of the political economy aimed at tackling: the under-regulated financialization of the health sector; the abuse of intellectual property rights; the control of key sectors in the health domain by a few oligopolistic corporations; and the high levels of tax avoidance that enable and perpetuate wealth extraction and inequality.Such an agenda may also require global health actors to question their own actions, whether they have tacitly legitimized stakeholders involved in exploitative and extractive practices by including them in health and humanitarian partnerships, or whether they have endorsed charitable projects and philanthro-capitalist models of development that have not been independently and critically evaluated. 60

Conclusion
Colonialism manifests in various ways and at different scales.Ultimately, all forms of colonialism are manifestations of power imbalances, and any process of decolonization must therefore challenge how these imbalances are produced and sustained.We have stressed the importance of the financial and corporate forms of contemporary colonialism, while acknowledging the need to address the legacies of the historical territorial and racial forms of colonialism.In doing so, we argue that global health must not only correct historical power imbalances within global health, but also challenge the way global health itself may be colonized, and actively resist unethical and harmful profiteering that can occur through the health economy.
Monopolistic and exploitative markets, harmful marketing and profitmaking, tax abuse, and the use of private wealth to undermine democratic governance and the public interest are the main barriers to freeing global health from historical and contemporary forms of colonialism.Overcoming these challenges calls for a political and economic anticolonialism as well as social decolonization aimed at ensuring greater national, racial, cultural and knowledge diversity within the structures of global health.